县域城镇数字家庭心脏康复模式探讨

Discussion on Cardiac Rehabilitation Model of Digital Family in County and Town

县域城镇介于城市和农村之间,其心脏康复具有特殊性。由于经济发展相对缓慢、健康信息交流局限、人口结构变动、不良健康生活方式等多方面不利因素,县域城镇心脏康复依从性和达标率低,但居民就近享有便捷康复服务的需求日益增强。针对县域城镇实际情况和心脏康复需求,宜因地制宜,进一步发挥互联网、大数据的平台作用,建立心脏康复防治网络,针对心血管群体进行规范化心脏康复管理十分必要。以家庭为单位的数字家庭心脏康复利用家庭内部资源和外部医疗相结合,在满足患者需求的同时,充分发挥家庭成员的能动性。数字家庭心脏康复模式是“实时监测、动态评估、及时预警、精准干预”和“家庭-社区家庭医师-医院专科医师三级联动”2个闭环服务和中西医有机结合一个策略,集预防、治疗、康复为一体的全闭环和全周期管理体系,并在团队人员、数字监测设备设施和监测指标、巡诊急救措施和评价指标方面建立质量控制标准,是理想的心脏康复模式。数字家庭心脏康复需进一步简廉智能化、趣味化,并强化三级联动、加速医养结合,为县域城镇心脏康复提供更好的机遇和发展空间。

County towns are between urban and rural areas,and cardiac rehabilitation has its particularity.Due to many unfavorable factors,such as relatively slow economic development,limited exchange of health information,changes in population structure and unhealthy lifestyle,the compliance and compliance rate of cardiac rehabilitation in counties and towns are low,but the demand of residents to enjoy convenient rehabilitation services nearby is increasing.In view of the actual situation and needs of cardiac rehabilitation in countie towns,it is appropriate to further utilize the platform of internet and big data to establish a cardiac rehabilitation prevention and control network,and it is very necessary to standardize cardiac rehabilitation management for cardiovascular groups.The family-based digital family cardiac rehabilitation utilizes the combination of internal family resources and external medical treatment to meet the needs of patients while giving full play to the motivation of family members.The digital family cardiac rehabilitation model implements two closed-loop services,namely“real-time monitoring,dynamic assessment,timely warning,precise intervention”and“three-level linkage between family and community family physician and hospital specialist”,and an organic combination of traditional Chinese and Western medicine,which integrates prevention,treatment and rehabilitation into a full closed-loop and full-cycle management system.It is an ideal model of cardiac rehabilitation to establish quality control standards in terms of team personnel numbers,monitoring equipment and facilities,monitoring indicators,first-aid measures and evaluation indicators.Digital family cardiac rehabilitation needs to be further simplified,intelligent and interesting,and to strengthen the three-level linkage and accelerate the integration of medical care,providing better opportunities and development space for cardiac rehabilitation in county towns.